What’s New in Research – April 2018

Research from BWH investigators demonstrate that health aid leads to immediate improvements in metrics of state stability across sub-Saharan Africa

How much does the U.S. government spend on foreign aid and what is the impact of that support? This question has taken on new urgency with the current administration’s proposals to dramatically reduce foreign spending. BWH researchers have taken the question of the impact of foreign health aid with results that should inform critical policy decisions around allocation. Their findings are published in Global Public Health.

BWH researchers, led by Vinay Gupta, MD, of the BWH Division of Pulmonary and Critical Care Medicine, have studied the impact of U.S. aid in health care on stabilizing fragile economies and found that in Sub-Saharan countries, U.S. health investments not only improve population health outcomes, but strengthen governance indices contemporaneously. Their results demonstrated a novel finding: U.S. health aid leads to immediate improvements in metrics of state stability across sub-Saharan Africa.

Gupta describes his interest and work in global health: “I’ve long been interested in the intersection of global health and international affairs, understanding how novel concepts such as health diplomacy can further the reach of health aid and help make recipients countries not only more healthy, but safer and more secure. The political dimensions of global health are crucially important to understand, as doing so will help ensure that financial commitments remain robust.”

The novel nature of these findings comes at a time when the U.S. government has divested from Centers for Disease Control and Prevention (CDC) operations in countries around the world. Understanding the value of CDC work is key to making wise foreign policy choices, according to Gupta. Gupta’s research is empirical and addresses questions that are routinely raised in popular media.

“By demonstrating the impact of global health investment health care leaders have powerful evidence to counter doubts about the remarkable value of this work,” said Gupta.

The authors report no potential conflict of interest or funding sources.

Excessive sleepiness can cause cognitive impairments and put individuals at a higher risk of motor vehicle crash. However, the perception of impairment from excessive sleepiness quickly plateaus in individuals who are chronically sleep deprived, despite continued declines in performance. Individuals may thus be unaware of their degree of impairment from sleep deficiency, which raises the question of whether these individuals are at an increased risk of motor vehicle crash. A team of researchers from Brigham and Women’s Hospital addressed this question and their results are published in BMC Medicine.

“We found that chronically sleep-deprived individuals don’t perceive themselves as being excessively sleepy and thus don’t perceive themselves as impaired,” said lead author Daniel J. Gottlieb, MD, MPH, associate physician in the Division of Sleep and Circadian Disorders at BWH. “This resulted in an increased risk of motor vehicle crashes in sleep-deprived individuals.”

The prospective study examined the relationship between motor vehicle crashes and two common causes of sleep deficiency – insufficient sleep duration and obstructive sleep apnea. The cohort in the study were participants in the Sleep Heart Health Study, a community-based study of the health consequences of sleep apnea, comprised of 1,745 men and 1,456 women between the ages of 40 and 89.

Obstructive sleep apnea is a chronic sleep disorder in which breathing repeatedly starts and stops during sleep, drastically reducing the quality of sleep and increasing sleepiness. An estimated one-sixth of adult women and one-third of adult men in the U.S. suffer from obstructive sleep apnea. Insufficient sleep duration is also common in the U.S. population, with an estimated 25-30 percent of U.S. adults sleeping six or fewer hours per night, a duration associated with excessive sleepiness.

Severe sleep apnea was associated with a 123 percent increased risk of motor vehicle crash, and mild to moderate sleep apnea was associated with a 13 percent increased risk of motor vehicle crash. These numbers were in comparison to those with no sleep apnea. Sleeping six hours per night was associated with a 33 percent increased crash risk, compared to sleeping seven or eight hours per night. Gottlieb added that this increased risk of crash was independent of an individual’s self-reported sleepiness.

“To help reduce these crash risks we need to identify individuals with sleep apnea and ensure they are properly treated for their apnea. We also need to increase public awareness of the importance of a good night’s sleep to reduce the percentage of the population with insufficient sleep duration,” said Gottlieb. “Ultimately, we would like to be able to identify a biomarker for cognitive impairments due to excessive sleepiness.”

This study used data from the Sleep Heart Health Study which was supported by National Heart, Lung and Blood Institute.

Nationwide analysis reveals large number of patients 65 and older died in the hospital or were discharged to a nursing home following emergency intubation

Intubation in the emergency department is common and can prevent a patient from dying from a reversible condition. While the benefits of such intubation for young and otherwise healthy patients are clear, it is less obvious whether the benefits of intubation outweigh the risks in older patients. A new study by researchers at Brigham and Women’s Hospital investigated the outcomes for patients aged 65 and older after emergency department intubation across a variety of conditions and disease. Their results are published in Journal of the American Geriatrics Society.

“A surprisingly large number of older patients who underwent intubation in the emergency department either died in the hospital or were discharged to a nursing home,” said lead author Kei Ouchi, MD, MPH, of the Department of Emergency Medicine at BWH. “On average, one-third of patients over 65 who received intubation in the emergency department died in the hospital.”

The retrospective study examined the outcomes of more than 41,000 adults aged 65 and older who were intubated in the emergency departments from 262 hospitals across the U.S. between 2008 and 2015. The study found that, overall, 33 percent of these patients died in the hospital after receiving intubation, 24 percent were discharged home, and 41 percent were discharged to a location other than home, such as a nursing home.

The researchers found that in-hospital mortality following intubation was worse for patients over 90 than any other group, with 50 percent of those patients dying in the hospital following intubation, and 14 percent of these patients being discharged home. However, the outcomes were not drastically better for patients on the younger side of the study, with 29 percent patients between 65 and 74 dying in hospital following emergency intubation, and only 31 percent of these patients being discharged home.

“It’s important that older patients, their families and their care team are aware of this information and can use it to make informed, shared decisions about whether the patient should receive emergency intubation should such intubation be needed,” said Ouchi. “It is difficult to make informed decisions on whether to provide intubation in older patients in an emergency situation because this is a very stressful and emotional time. Older patients, their families, and care providers are encouraged to make this decision before emergency situations requiring emergency department admission and intubation arise.

There was no conflict of interest or sponsor for any of the authors of the study.

Randomized clinical trial finds that older men who consumed more protein than the recommended dietary allowance did not see increases in lean body mass, muscle performance, physical function or other well-being measures.

Regardless of whether an adult is young or old, male or female, their recommended dietary allowance (RDA) for protein, set by the Institute of Medicine, is the same: 0.8-g/kg/day. Many experts and national organizations recommend dietary protein intakes greater than the recommended allowance to maintain and promote muscle growth in older adults. However, few rigorous studies have evaluated whether higher protein intake among older adults provides meaningful benefit. A randomized, clinical trial conducted by Brigham and Women’s Hospital investigator Shalender Bhasin, MD, and colleagues has found that higher protein intake did not increase lean body mass, muscle performance, physical function or other well-being measures among older men. The results of their study are published in the April issue of JAMA Internal Medicine.

“It’s amazing how little evidence there is around how much protein we need in our diet, especially the value of high-protein intake,” said corresponding author Bhasin, director of the Research Program in Men’s Health in the Division of Aging and Metabolism at BWH. “Despite a lack of evidence, experts continue to recommend high-protein intake for older men. We wanted to test this rigorously and determine whether protein intake greater than the recommended dietary allowance is beneficial in increasing muscle mass, strength and wellbeing.”

The clinical trial, known as the Optimizing Protein Intake in Older Men (OPTIMen) Trial, was a randomized, placebo-controlled, double-blind, parallel group trial in which men aged 65 or older were randomized to receive a diet containing 0.8-g/kg/day protein and a placebo injection; 1.3-g/kg/day protein and a placebo injection; 0.8-g/kg/day protein and a weekly injection of testosterone; or 1.3-g/kg/day protein and a weekly injection of testosterone. All participants were given prepackaged meals with individualized protein and energy contents and supplements. Seventy-eight participants completed the six-month trial.

The team found that protein intake greater than the RDA had no significant effect on lean body mass, fat mass, muscle performance, physical function, fatigue or other well-being measures.

“Our data highlight the need for re-evaluation of the protein recommended daily allowance in older adults, especially those with frailty and chronic disease,” the authors concluded.

This study was funded primarily by a National Institutes of Health grant from the National Institute on Aging. Additional support was provided by the infrastructural resources of the Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies. A full listing of funding sources, conflict of interest disclosures and more are available in the published paper.

Patients Who Travel Abroad for Plastic Surgery Can Bring Home Serious Complications

Brigham and Women’s study on “medical tourism” trend reveals substantial problems, risks, as well as effect on U.S. health system

With the promise of inexpensive procedures luring patients to travel abroad for plastic surgery, medical tourism has become an expanding, multi-billion-dollar industry. But while the initial procedure may be cheap, it can place a significant burden on U.S. public health systems when patients return from abroad with complications. A new study by investigators at Brigham and Women’s Hospital describes the magnitude of medical complications that can result from plastic surgery abroad. Their study is published in Plastic and Reconstructive Surgery.

“Many think of medical tourism as wealthy patients traveling to receive care at high quality medical institutions abroad, but what we’re reporting on here are repercussions that can result when patients return to their home countries to undergo elective plastic surgery procedures at a lower price,” said senior author Dennis Orgill, MD, PhD, medical director of Brigham and Women’s Hospital’s Wound Care Center. “Patients need to be very cautious when they go outside of the U.S. for elective plastic surgery. The safety and regulatory systems that protect patients in the U.S. are often not in place in a patient’s home country.”

In a retrospective analysis, Kimberly Ross, MPH, Orgill and colleagues evaluated patients who had been treated at BWH over the last seven years for complications or complaints associated with plastic surgery performed in a developing country. Of the 78 patients evaluated, the most common complications were seen following abdominoplasty (35 patients) or breast augmentation (25 patients). The most common destination country for these surgeries was the Dominican Republic – 75 percent of the patients in the study traveled there for elective procedures.

Complications included infections, pain and wound-healing issues. Fourteen patients presented with infections at their surgical sites, including infection from multi-drug resistant bacteria. Eight patients required the removal of damaged tissue or foreign objects from the wound site over a series of office visits.

The team also found that most patients relied on their medical insurance to cover the cost of follow-up care when they returned to the U.S. About 60 percent of the patients studied were on Massachusetts Medicaid. Four patients in the study admitted to returning to their original surgeon – despite complications – for a second surgical procedure abroad.

“We hope that this study will bring attention to this emerging issue and encourage others to report any results related to medical tourism treatment and patterns,” the authors wrote.

The authors declare no financial interest in relation to the content of their article.

An Automated Notification System Improves Follow-Up of Actionable Tests Pending at Discharge

Study demonstrates that implementation of an automated notification system can improve follow-up on actionable tests pending at discharge, particularly when both the discharging attending physician and primary care provider of a patient use the system

Many patients are discharged from the hospital with pending tests. For example, a patient may be awaiting biopsy results for a mass that may turn out to be cancerous, may have had blood cultures drawn that unexpectedly return positive, or may have had their Vitamin D levels tested which might come back low. A surprisingly large number of these tests pending at discharge (TPAD) are not followed up. The proportion of TPADs with documented follow-up is variable across institutions, but can be as low as 20 percent, meaning that up to 80 percent of patients awaiting results may never receive follow-up on those tests. A new study by researchers from Brigham and Women’s Hospital demonstrates that the implementation of a simple automated notification system can improve TPAD follow-up. Their results are published in Journal of General Internal Medicine.

“There is a communication gap between attending physicians based in the hospital and primary care doctors located elsewhere which can lead to important test results being missed,” said corresponding author Anuj K. Dalal, MD, Hospitalist at BWH. “We found that implementing a simple automated notification system can help bridge this communication gap.”
The automated notification system significantly improved the time to documented action for TPADs, meaning that patients received follow-up on their results much faster. Patients whose primary care physicians received automated notifications had significantly higher rates of documented follow-up for actionable TPADs than patients whose primary care physicians did not receive notifications.

While the notification system resolved many issues surrounding follow-up of TPADs, it didn’t completely solve the problem. Even with the automated notification system there were still approximately 40 percent of patients who had no evidence of documented follow-up for actionable TPADs, including several patients with biopsy specimens that revealed malignancies.

To address this gap, Dalal and his team envision integration of newer digital health tools with the hospital’s electronic health record that not only notifies discharging attending physicians and primary care physicians, but that empowers patients to make sure their test results are followed-up in a timely manner.

“Just like you might get an automated notification, notifying you of the delivery of a package, we hope to implement such an automated system that notifies patients, primary care providers, and attending physicians when it is time to follow-up high-risk test results,” said Dalal. The next step for the researchers is to integrate such “smart” notification tools with the hospital’s electronic health records and evaluate their effectiveness.

This study was supported by a grant from CRICO/Risk Management Foundation of the Harvard Medical Institutions.